Page 37 - World Association of Laparoscopic Surgeons - Journal
P. 37
WJOLS
Prevention of Common Bile Duct Injuries in Laparoscopic Cholecystectomy
use knowledge of psychologic factors in the production of 3. Deziel DJ, Millikan KW, Economou SG, et al. Complications
of laparoscopic cholecystectomy: A national survey of 4,292
error. This is the human factors approach described by
hospitals and an analysis of 77,604 cases. Am J Surg 1993;165:
Reason in ‘high-reliability organizations’, such as air-traffic
9-14.
control and the nuclear power industry. 31 In such 4. Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG.
environments, highly trained professionals carry out Bile duct injury during laparoscopic cholecystectomy: Results
complex technical tasks and are sometimes required to make of a national survey. Ann Surg 2001;234:549-59.
5. Richardson MC, Bell G, Fullarton GM. Incidence and nature of
rapid decisions in conditions of uncertainty with potentially
bile duct injuries following laparoscopic cholecystectomy: An
disastrous consequences of mistakes. Some error is audit of 5,913 cases. West of Scotland Laparoscopic Chole-
inevitable when human beings interact with complex cystectomy Audit Group. Br J Surg 1996;83:1356-60.
technical environments, as in the operating room. A specific 6. Hugh TB. New strategies to prevent laparoscopic bile duct
injury—surgeons can learn from pilots. Surgery 2002;132(5):
type of error, recognized as the cause of some aircraft
826-35.
crashes, seems to operate in many cases of bile duct injury:
7. Gossage JA, Forshaw MJ. Prevalence and outcome of litigation
The false hypothesis or deadly mind-set error. A mistaken claims in England after laparoscopic cholecystectomy.
perception, that a particular duct is the cystic duct, provides International Journal of Clinical Practice 2010;64(13);1832-35.
8. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of
the setting for this type of error in cholecystectomy. The
major biliary injury during laparoscopic cholecystectomy. Ann
surgeon may develop a functional fixity and reject evidence
Surg 1992;215:196-202.
of a mistake. The unwillingness of juniors to question the 9. Schol FP, Go PM, Gouma DJ. Risk factors for bile duct injury
actions of seniors has been identified as a significant in laparoscopic cholecystectomy: Analysis of 49 cases. Br J
contribution to errors in the operating room. The Surg 1994;81:1786-88.
10. Russell JC, Walsh SJ, Mattie AS, Lynch JT. Bile duct injuries
characteristics of a surgeon at low risk for error is often
1989-93: A statewide experience. Connecticut Laparoscopic
identified as being a person who expects unpleasant Cholecystectomy Registry. Arch Surg 1996;131:382-88.
surprises; accepts input from others; is ready to modify 11. Ooi LLPJ, Goh YC, Chew SP, et al. Bile duct injuries during
hypotheses; and recognizes the effects of self-fatigue, time laparoscopic cholecystectomy: A collective experience of four
teaching hospitals and results of repair. Aust NZJ Surg
pressures, and personal worries on surgical performance.
1999;69:844-46.
Hunter suggested that a team approach may be beneficial,
12. Cates JA, Tompkins RK, Zinner MJ, Busuttil RW, Kallman C,
stating that the cystic duct should not be clipped until all Roslyn JJ. Biliary complications of laparoscopic cholecystec-
members of the operating team are contented that the tomy. Am Surg 1993;59:243-47.
dissection is complete. 16 13. Strasberg SM. Avoidance of biliary injury during laparoscopic
cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:
543-47.
CONCLUSION
14. Strasberg SM, Eagon CJ, Drebin JA. The hidden cystic duct
syndrome and the infundibular technique of laparoscopic
Bile duct injuries have cast a shadow of apprehension on
cholecystectomy—the danger of the false infundibulum. J Am
an otherwise wonderful procedure of laparoscopic
Coll Surg 2000;191:661-67.
cholecystectomy. Millions have benefited from this advance 15. Francoeur JR, Wiseman K, Buczkowski AK, Chung SW,
against gallbladder disease. Hence, to preserve these Scudamore CH. Surgeons’ anonymous response after bile
benefits, the operating surgeon has to be aware of the factors duct injury during cholecystectomy. Am J Surg 2003;185:
468-75.
responsible for these injuries and take appropriate measures
16. Hunter JG. Avoidance of bile duct injury during laparoscopic
to prevent them. This requires strict adherence to the cholecystectomy. Am J Surg 1991;162:71-76.
principles of meticulous dissection so that only positively 17. Troidl H. Disasters of endoscopic surgery and how to avoid
identified structures are divided. Routine use of them: Error analysis. World J Surg 1999;23:846-55.
18. Strasberg SM. Error traps and vasculobiliary injury in
intraoperative cholangiograms and converting to open
laparoscopic and open cholecystectomy. J Hepatobiliary
procedure in the event of failure to progress or uncertain
Pancreat Surg 2008;15:284-92.
anatomy would go a long way in significantly reducing this 19. Strasberg SM. Rationale and use of the critical view of safety in
mishap. laparoscopic cholecystectomy. J Am Coll Surg 2010;211(1):
132-38.
REFERENCES 20. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C.
One thousand laparoscopic cholecystectomies in a single surgical
1. Soper NJ, Brunt LM, Kerbl K. Laparoscopic general surgery. unit using the critical view of safety technique. J Gastrointest
N Engl J Med 1994;330:409-19. Surg 2009;13:498-503.
2. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem 21. Yegiyants S, Collins JC. Operative strategy can reduce the
of biliary injury during laparoscopic cholecystectomy. J Am incidence of major bile duct injury in laparoscopic cholecystec-
Coll Surg 1995;180:101-25. tomy. Am Surg 2008;74(10):985-87.
World Journal of Laparoscopic Surgery, January-April 2012;5(1):27-32 31